Evaluation of State-Led Surveillance of Neonatal Abstinence Syndrome — Six U.S. States, 2018–2021

Opioid use disorder (OUD) is a significant public health problem in the United States, which affects children as well as adults. During 2010-2017, maternal opioid-related diagnoses increased approximately 130%, from 3.5 to 8.2 per 1,000 hospital deliveries, and neonatal abstinence syndrome (NAS) increased 83%, from 4.0 to 7.3 per 1,000 hospital deliveries (1). NAS, a withdrawal syndrome, can occur among infants following in utero exposure to opioids and other psychotropic substances (2). In 2018, a study of six states with mandated NAS case reporting for public health surveillance (2013-2017) found that mandated reporting helped quantify NAS incidence and guide programs and services (3). To review surveillance features and programmatic development in the same six states, a questionnaire and interview with state health department officials on postimplementation efforts were developed and implemented in 2021. All states reported ongoing challenges with initial case reporting, limited capacity to track social and developmental outcomes, and no requirement for long-term follow-up in state-mandated case reporting; only one state instituted health-related outcomes monitoring. The primary surveillance barrier beyond initial case reporting was lack of infrastructure. To serve identified needs of opioid- or other substance-exposed mother-infant dyads, state health departments reported programmatic successes expanding education and access to maternal medication for opioid use disorder (MOUD), community and provider education or support services, and partnerships with perinatal quality collaboratives. Development of additional infrastructure is needed for states aiming to advance NAS surveillance beyond initial case reporting.

Opioid use disorder (OUD) is a significant public health problem in the United States, which affects children as well as adults. During 2010-2017, maternal opioid-related diagnoses increased approximately 130%, from 3.5 to 8.2 per 1,000 hospital deliveries, and neonatal abstinence syndrome (NAS) increased 83%, from 4.0 to 7.3 per 1,000 hospital deliveries (1). NAS, a withdrawal syndrome, can occur among infants following in utero exposure to opioids and other psychotropic substances (2). In 2018, a study of six states with mandated NAS case reporting for public health surveillance (2013)(2014)(2015)(2016)(2017) found that mandated reporting helped quantify NAS incidence and guide programs and services (3). To review surveillance features and programmatic development in the same six states, a questionnaire and interview with state health department officials on postimplementation efforts were developed and implemented in 2021. All states reported ongoing challenges with initial case reporting, limited capacity to track social and developmental outcomes, and no requirement for long-term follow-up in state-mandated case reporting; only one state instituted healthrelated outcomes monitoring. The primary surveillance barrier beyond initial case reporting was lack of infrastructure. To serve identified needs of opioid-or other substance-exposed motherinfant dyads, state health departments reported programmatic successes expanding education and access to maternal medication for opioid use disorder (MOUD), community and provider education or support services, and partnerships with perinatal quality collaboratives. Development of additional infrastructure is needed for states aiming to advance NAS surveillance beyond initial case reporting.
A 2018 study (3) identified six states (Arizona, Florida, Georgia, Kentucky, Tennessee, and Virginia) with laws mandating NAS case reporting by applying specific criteria focusing on laws across all 50 states and the District of Columbia that explicitly named "neonatal abstinence syndrome" in disease and conditions reporting laws. Although each state reported distinct pathways for law enactment, state officials consistently indicated that the purpose for mandating NAS reporting was to characterize both NAS incidence and impact in the state and to identify more severely affected communities and opportunities for programmatic development. One of the main findings from that study indicated that mandated reporting helped quantify NAS incidence and guide programs and services.
Accordingly, the overarching aim of the current study was to review surveillance features and program development by the same six states, after the enactment of state laws, to better understand NAS surveillance beyond initial case reporting. Thus, this qualitative study was designed to examine longerterm surveillance and programs developed postimplementation as a primary objective, and changes since the 2018 study in data collection and quality assurance practices as a secondary objective. Epidemiologists and birth defects program managers from all six states completed the 34-item questionnaire and semistructured follow-up telephone interview during February-April 2021. Questionnaire and interview data were analyzed for similarities and differences in initial case reporting (timeliness, reporting criteria, and completeness) and features beyond initial case reporting (outcomes follow-up, quality assurance measures, and resources used) and, although not directly linked to surveillance programs, subsequent programmatic development since enactment of state-mandated NAS case reporting. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.* A review of the programs indicated both differences and similarities across the six states' surveillance features ( Kentucky also uses case reporting to characterize hospital discharge disposition for mother and infant. Alongside information on surveillance extending beyond initial case reporting, states also noted numerous ongoing case reporting challenges ( Table 2). These include collecting missing information (e.g., race or ethnicity, toxicology data, and substance exposure history) for mother or infant; assessing data accuracy from electronic health records, claims data, and medical record abstraction; sharing reports with other agencies; and de-duplicating data received from multiple sources.
To reduce missing data, Kentucky and Tennessee instituted mandatory data fields and linkage of case reporting to vital records. Georgia noted that providing reporter education on case reporting best practices and partnering with national laboratories for electronic reporting of positive infant toxicology were helpful to initial case reporting efforts.
States were asked about resources most and least helpful to surveillance efforts. Georgia and Tennessee noted that partnership with reporting hospital personnel and the use of free web-based reporting tools were helpful. Arizona officials noted that using an existing state disease reporting system streamlined hospital-based case reporting but noted that their state's NAS case definition only accounted for opioids. Georgia reported that even after transitioning to the CSTE case definition, opportunities for improvement remain, including case definition implementation by medical provider and facilities to continue standardizing reporting using clinical and administrative data sources. Florida, Georgia, Kentucky, Tennessee, and Virginia reported that partnering with perinatal quality collaboratives was helpful for ongoing surveillance efforts offering improvement opportunities for 1) case reporting, data collection, and data quality; 2) clinician education on resources for opioid and substance-exposed infants and mothers, and 3) health outcomes tracking.
States were also asked about monitoring health-, social services-, and developmental-related outcomes. No states reported available capacity to follow up on use of social

Summary
What is already known about this topic?
Increasing diagnoses of maternal opioid use disorder and neonatal abstinence syndrome (NAS) continue to affect U.S. communities. During 2018, a study of six states with mandated NAS case reporting for public health surveillance (2013-2017) found that mandated reporting helped quantify NAS incidence and inform programs and services.
What is added by this report?
A follow-up study of these states found continued advantages in determining NAS incidence and community exposure patterns to guide state program development. However, persistent data collection challenges and infrastructural gaps influence states' capacity for longer-term surveillance beyond initial case reporting.
What are the implications for public health practice?
States considering surveillance beyond initial case reporting might benefit from understanding opportunities and challenges related to necessary infrastructure and resource development to facilitate longer-term public health follow-up. services or developmental-related outcomes. With the exception of Kentucky, states reported that they did not monitor health-related outcomes. Kentucky has instituted state-level monitoring of infant hospitalization and comorbidity rates, and preventive health maintenance and vaccination rates, facilitated by direct linkage and data-sharing with their state Medicaid program. Overall, officials reported a lack of infrastructure (personnel, resources, and data linkages) within state health departments and outside agencies as primary reasons for limited long-term surveillance of NAS. Florida described their passive case reporting system as limiting timeliness, accuracy, and data completeness, and consequently, affecting downstream follow-up and surveillance.

Discussion
The current study was designed to review NAS surveillance beyond initial case reporting and program development after implementation of state-mandated NAS case reporting; however, none of the six states report follow-up of infants or families beyond the initial NAS case report. Notably, initial state reporting mandates were intended to improve shortterm timeliness of NAS epidemiologic data collection, not necessarily long-term follow-up or surveillance. Consequently, most reporting programs were not initially linked to existing health, social services, or developmental follow-up programs within states, explaining the significant data-sharing gap. Only one state has been able to monitor infant health-related outcomes and, despite ongoing interest in long-term outcomes, none of the six states has been able to track use of social services or development-related outcomes. The states cited critical infrastructure gaps as limiting their ability to conduct longer-term surveillance and reported distinct care access gaps in rural communities (e.g., geographic and internet bandwidth limitations). This limitation is concerning given 2004-2017 data showing disparities in OUD and NAS incidence across rural versus urban regions and remote rural counties (1,5,6). Considerations for infrastructure development to support long-term surveillance include capacity-building measures for 1) sufficient personnel (e.g., epidemiologist, data or information technology manager, or developmental specialist), 2) technical architecture (electronic system for housing longer-term surveillance data or data linkages to other state systems), and 3) legislative pathways to address potential confidentiality barriers regarding data-sharing between state health departments and other state agencies.
Despite state health department-reported infrastructural limitations in surveillance beyond initial case reporting, the six states with mandated NAS reporting have been able to achieve several noteworthy programmatic developments to serve identified needs of opioid and substance-exposed motherinfant dyads. Many of these developments focus on educational programs for medical providers and families to serve identified needs of opioid and substance-exposed infants and families, including stigma reduction (Arizona, Kentucky, and Tennessee). Georgia has implemented a quality improvement initiative centering around hospital educational outreach to improve NAS care management. Tennessee conducted educational outreach to providers of MOUD and local jails to expand access to contraception for persons voluntarily seeking access. Virginia provides educational teleconsultation to medical providers on OUD prevention and treatment. Florida is in the process of applying the Plan of Safe Care model for infants and families to a parallel program identifying pregnant women with OUD to link to MOUD, essential for a mother-infant dyad care model (7,8). With respect to policy enactment, Tennessee has broadened voluntary long-acting reversible contraception The findings in this report are subject to at least two limitations. First, because this analysis relies largely on qualitative data, it cannot quantify the impact of NAS surveillance in the six states. Second, this study is a follow-up of six states with mandated NAS case reporting implemented during 2013-2017; other states with reporting statutes and regulations not meeting the search criteria from the 2018 study are not included (9). As such, study findings from these six states might not be generalizable.
Although mandated NAS case reporting offers opportunities for short-term epidemiologic data collection, continued case reporting and infrastructural challenges limit the breadth of short-and long-term surveillance. With resource-and capacity-building assessments and responding actions, state health departments might be better prepared to bridge the gap between initial case reporting and longer-term needs analysis and support for affected infants and families.